Narrative Medicine

Western medical care system has mainly relied on a biomedical approach that treated disease/illness through examination of measurable biological variables such as blood work, X-ray, MRI and physical examination. It often ignored psychological, behavioral, and socio-cultural characteristics germane to the individual patient (Engel, 1977). By the late 1990s, physicians like Dr. Remen (2006) and Dr. Charon (2001) have advocated for patient-centered narrative medicine and urged that medical practice should be structured around the narratives of patients. Narrative Medicine, defined as medicine practiced with the narrative competence to recognize, understand, absorb, interpret, and be moved by the stories of illness (Charon, 2001). It addresses the need of patients and caregivers to voice their experience, to be heard and to be valued, and it acknowledges the power of narrative to change the way care is given and received.

The narrative process offers individuals a chance to conceptualize their lives and their identities and to share their stories with medical professionals. The process of personal narrative can have a cathartic effect which helps individual form a new sense of identity following his/her illness (Lorenz, 2010). Patient’s narrative provides clinicians a glimpse into the physical, psychological, social, and economic impact of an illness and how that illness affects the individual, the family, and the community. As such, narratives can guide the clinician in holistic approach and inform clinical decision-making in patient-centered care (Frass, 2015).

There is no doubt that everyone in this world for being a patient would applaud the idea of narrative medicine. However, as every family doctor clinic is busy rushing patient in and out the clinic for less than 10 minutes per visit, the stressed-out, overworked doctors, seeing too many patients in too short a time, couldn’t even collect full patient histories relating to the specific illness, the feasibility of narrative medicine in Canadian medical care system is questionable.

Dr. Rita Charon  –  Professor of Clinical Medicine and Executive Director of the Program in Narrative Medicine at Columbia University and a Cecil H. and Ida Green Visiting Professor at Green College, UBC, who will be presenting at Richmond Hospital Dept of Psychiatry Annual Clinical Day on Friday April 8/2016 in Richmond Hospital. For registration, please go to https://rhp2016clinicalday.eventbrite.ca/?discount=GEN

Relevant readings:

Rita Charon. Narrative Medicine: Honoring the Stories of Illness. New York, Oxford University Press, 2008.

Power Point: https://www.meded.uci.edu/medhum/presentations_mh/Narrative%20Medicine.Grand%20Rounds.rev.pdf   Narrative Medicine in Practice by Johanna Shapiro, Ph.D. Professor, Department of Family Medicine; Director, Program in Medical Humanities & Arts, University of California Irvine, School of Medicine

References

Charon, R (2001). “Narrative medicine: A model for empathy, reflection, profession, and trust”. JAMA: The Journal of the American Medical Association 286 (15): 1897–1902.doi:10.1001/jama.286.15.1897. ISSN 0098-7484.

Engel, G. L. (1977). The need for a new medical model: A challenge for biomedicine. Science, 196(4286), 129–136

Fraas, M. R. (2015). Narrative medicine: Suggestions for clinicians to help their clients construct a new identity following acquired brain injury. Topics In Language Disorders, 35(3), 210-218. doi:10.1097/TLD.0000000000000063

Remen, Rachel Naomi (2006). Kitchen Table Wisdom: Stories That Heal. Riverhead Books. ISBN 9781594482090.

The Struggle of Being a Hopeless Romantic

This is a quote from my colleague Darlene S., very poetic :

The struggle with being a hopeless romantic is that most people don’t live up to the ideal you hold up in your head. So very few can capture your imagination, no matter how hard they try. Yet a hurried glimpse from a perfect stranger can set your mind ablaze. And feed your dreamy soul for many endless hours, dreaming dreams that will never see the light of day… fantasies, illusions. You know better but can’t stop your mind from drifting, back into a world where fairy tales reign and prince charming awaits. You willingly cast away reality in favour of fantasy. Better be alone than settle you say. So on you go dreaming your life away..

Below is the translation of her words in Chinese from me:

一个无可救药的浪漫主义者最大的痛苦在于大多数人无法达到你的期望。极其少有的人能够明白你脑中的天马行空，纵然尽其所能。然而，萍水相逢的惊鸿一瞥却完美的让你迷途火海，你迷样的灵魂坠入你的梦中的世界不知归途不见天日… 痴迷也罢,幻影也罢… 你明知不可为，却无力阻止自己深陷坠落于你那公主王子的梦幻童话。梦里不知身是客，一晌贪欢。奈何弱水三千，只取一瓢饮，绝决如你。流水落花春去也，从此路人，岁月蹉跎！

Anxious? Take deep breaths with this GIF!

Transactional Analysis in Psychotherapy

The development of counseling and psychotherapy over last 100 years has drawn a significant number of influential psychological theories on mental illness from different perspectives.  Transactional analytic (TA) therapy has its root in psychodynamic therapy, shares its philosophy with humanistic approach, and its characteristics with the behavioral approaches (Stewart & Tilney, 2000). The fundamental teaching of this process, as determined by Berne (1961) is that there are historical mal-adaptations embedded in what is known as the childhood script, namely the process of repeating childhood behaviors and ideas throughout life.  These need to be addressed through problem solving as opposed to avoidance or passivity in relation to new challenges in the person’s life (Berne, 1961).

Transactional therapy is developed on the philosophical assumptions that human interact with others by subconsciously utilizing three ego-states (Adult, Parent, and Child) based on the life-script once written to meet survival needs in childhood but may no longer valid,  and everyone has the capacity to consciously make decisions and change through therapy (Stewart & Tilney, 2000). In the Theory of TA, it’s believed that individuals have three separate, functional ego states: Child, Adult, and Parent. Child Ego State: childlike behaviors and feeling, including Free Child & Adaptive Child. Free Child: spontaneous, creative, impulsive, feeling oriented, and self –centered. Adaptive Child: the compliant self, follows the rules learned in childhood to get needs met. Parent Ego Sate is originated in early childhood interactions, are carried through the life span, including Nurturing Parent (comforts, praises) and Critical Parent (disapproves, finds faults).  Adult Ego State approaches life events by gathering the facts from external and internal ego status, processing information, and maintaining balance among Parent and Child ego states. In TA therapy, both counselors and clients must understand which ego states are functioning in their specific problem areas.

When individuals are in the Child ego state, he/she submits readily to others’ needs and demands, thus feel uncomfortable and resentful as a result; when in the Parent state, he/she becomes judgmental, and feels superior to others; the most appropriate ego-state of relating to others is through the Adult ego state in which individuals meet others as mature, equal beings. Through this therapy, the therapist assists clients to increase their awareness of how their current behavior/thoughts are being affected by the “scripts” they received and incorporated as children, explore how this “scripts” were made as a result of childhood experience, and develop the spontaneity and capacity to free themselves from those “scripts” that are no longer working and to make alternative way of thinking, behaving, and living.

According to Adams (2008), every individual craves strokes, the transactions to get their needs met, including negative & positive strokes. Scripts are the patterns of interpersonal behaviors and intrapersonal dialogues to get their strokes, which are written by childhood experience, individuals continue to follow those scripts in adulthood unless they are promoted or challenged to change. By entering the counseling work, clients have to have own desire or motivations to change their behavioral scripts, counselors should assist clients to work on several transactional states: to quiet the Critical Parent ego state and to empower the Adaptive Child to feel safe physically, emotionally and mentally, to enjoy the spontaneity of life with the Free Child ego state, to validate from and to strengthen the Nurturing Parent, and to empower the Adult to bring a healthier balance to the diverse ego states.  Adams (2008) believes that in order for individuals to move beyond memories (the script) to forgiveness, the Adaptive Child must realize that the past is NOT his/her fault and must let go off guilt and blame, and the Worst Enemy is self-hatred that weave the web of unhappiness. Individuals need to explore personal history without getting stuck in history, and the effective approach is releasing anger associated with the debt without seeking repayment. Adams (2008) affirms that experience learned in childhood can be unlearned in adulthood with proper techniques and training. Using TA, individuals can gain awareness and insight into their own meanings around life issues, and empower themselves to change their behaviors to be consistent with their new internal, healthier messages.

One of the strengths of this approach is that it helps clients gain insight of their cognitive well-being through discovering the habitual strategies of dealing with people that they have made in early childhood under disadvantageous condition through structural analysis, script analysis, and game analysis. The equality of therapist-client relationship is stressed; therapist and client are seen as mutual allies in the therapeutic process in which the client initiates the contract with the help of therapist’s knowledge (Stewart & Tilney, 2000). TA provides a structured framework to help clients discover how their past experiences have a continuing influence on their present behavior, explore the connections between what they learned from past and their current attitudes/pattern in relating to others, and examine their basic assumptions of life situations. It enables clients to identify the sorts of relationship ‘games’ that they play with one another via these ego states and to learn more readily on an Adult-Adult basis.

Another strength of this approach, specifically useful to clients with multicultural backgrounds, is TA deals with power struggle. People with collective cultural background often experience a lack of the power to “be oneself” and some may have difficult to be assertive, the specific techniques of TA can enhance clients’ personal responsibility and empower them to make decision to bring the changes to their life. Those techniques include but not limit to structural analysis, transactional analysis, role playing, family modeling, analysis of games and rackets, teaching, and script analysis. As Stewart & Tilney (2000) affirm, this approach can be applied to a wide range of problems, including marital or relationship difficulties; stress reaction, and personality disorders. One of the main goals of a TA therapy is to facilitate insight of clients so that they are able to assume increased control of their thoughts, feelings, and actions.  Individuals are encouraged to develop the self-understanding, and to assume the responsibility of making changes both within themselves and in their transactions with others. Transnational therapy may work well with the combination with Gestalt approach because the latter facilitates emotional release while TA focuses cognitive aspects of thinking errors.

One of the limitations of TA may be its emphasis of cognitive aspect of human relationship and personality, and leave very limited attention for exploration of emotions. If this approach can be utilized with Gestalt approach, both cognitive and emotional dimension can be explored and integrated. Another limitation of TA is that it seems to have plenty of labels and jargon in this therapy, some clients may get ‘lost in translation” especially for those who are not familiar with western psychology. This therapy stresses achieving autonomy through a progressive process including social control, symptomatic relief, transference relief, and script cure, hence, TA may seem confrontational on some points, the therapist has to make efforts to respect others’ cultural beliefs and values while encouraging them break free from old “script” and live their life in a new and more resourceful way.

For more details on TA see TA 101 notes by Dave Spenceley TSTA at the following link:

http://www.psihoterapieat.ro/pdf/101.pdf

References

Adams, S. (2008). Using Transactional Analysis and Mental Imagery to Help Shame-Based Identity Adults Make Peace With Their Past. Adultspan: Theory Research & Practice, 7(1), 2-12. Retrieved from Psychology and Behavioral Sciences Collection database.

Berne, E. (1961). Transactional Analysis in Psychotherapy. New York: Simon and Schuster.

Stewart, I. & Tilney, T. (2000). Transactional Analysis. In S. Palmer (Ed), Introduction to counseling and psychotherapy: the essential guide (pp. 315-330). London, UK: Edward Arnold.

Tom, L. A. S.H. (1999). Health and health care for Chinese-American elders. Retrieved from http://www.stanford.edu/group/ethnoger/chinese.html